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Answer these questions, describing your situation, to get started.

You may request a version of this application,
that can be filled out and returned by e-mail.

This application can be printed off and mailed to
PO Box 762, Milton Freewater, OR 97862

Name____________________________ Birthdate__________

Sex______ Height______ Weight______ Grade in School_____



Phone____________________ e-mail_____________________

Needs Assessment

Type of disability:  Must check one to meet ADA guidelines.

Physical       , sensory       , psychiatric       , intellectual       , mental       ,

Specific type of assistance needed / tasks to train for: 
(The crime deterrent effects of an animals presence and the provision of emotional support, well-being, comfort, or companionship do not constitute work or tasks for the purposes of this definition.)

mobility       , pull wheelchair       , balance       , body adjustments       , hearing-alert       ,    open doors       , rescue work       , retrieval       ,       sight       , stability to stand       , stability to walk       ,
Other tasks:                                                                                         ,
medical treatment/safety alert       ,  allergens       , anaphylaxis       , anxiety       , asthma       , blood sugar       , cardiac       ,  autism       ,
hypertension       , fatigue       , carry medications and instructions       , concentration       , insomnia       , ptsd       , heart palpitations       , respiratory dysfunction       , seizures       , shortness of breath       , parkinsons        , OCD       , ADHD       , ADD       , migraines       ,
back pain       , other severe pain                                                          ,

Other conditions:                                                                                   ,

prevention and interruption of impulsive, repetitive behaviors       ,

specific behaviors:                                                                               ,

Do I have a Doctor's diagnosis for my condition(s)? Yes____ no____

My diagnosis is________________________________________

I use special equipment or devices?_________________________


Special Activities, such as work or school____________________


Describe in what ways you think a Service Dog could assist you.

Physical Assistance____________________________________
Psychological Support___________________________________

Emotional Support_____________________________________

Medical Alert_________________________________________

Special Needs_________________________________________

How will I take care of a dog's daily needs?




Medical Care__________________________________________

Training /Correction____________________________________

Where will my dog go for exercise and toileting________________


What is my living situation?

Rural community___ Suburb___ City___ Country property___

House___ Apartment___ Facility___ Other___________________

Do I need someone to assist me with my care?__________________


Who else lives in the home with me?_________________________


Ages of children living in the home?__________________________

What other animals live with me?___________________________


Who takes care of them?_________________________________
What pets have I had before?_____________________________


Who took care of them?_________________________________

What happened to pets I owned before?_____________________


By making this application, I am intending to be legally bound hereby, I understand and agree and do hereby release from liability and to indemnify and hold harmless Heritage Service Dogs, and any of its employees or agents representing or related to this Program. This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activities related to Heritage Service Dogs. I further agrees to abide by all the rules and regulations promulgated by the ADA and, Heritage Service Dogs.

By my signature, I declare as an authorized authority, that this filing has been examined by me and is, to the best of my knowledge and belief, true, correct, and complete. Making false statements in this document is against the law and may be penalized. By typing my name in the electronic signature field, I am agreeing to conduct business electronically with Heritage Service Dogs. I understand that transactions and/or signature in records may not be denied legal effect solely because they are conducted, executed, or prepared in electronic form and that if a law requires a record or signature to be in writing, an electronic record or signature satisfies that requirement. Please Note: Each Applicant and their legal representative must electronically sign this form.

If you are under 18 years of age, you will need a signature from your parent or guardian


Signature of Parent or Guardian



If you are under 18 years of age, you will need a signature from your parent or guardian

Signature of Parent or Guardian


There are many types and degrees of disability. Your situation is like no other. We do not train dogs for a disability, our goal is to train dogs for you, and your specific needs.

We comply strictly with ADA guidelines. By utilizing our products, services, training, or information you agree to comply with ADA guidelines as well.

Heritage Service Dogs holds your personal information in strictest confidence. It will only be used to assist you through the process of acquiring, training, working with your Service Dog.